Nursing Care Plans In 4 Simple Steps (2018)

In this video, I'm gonna walk you through a simple four step process to set yourself up for success to acing your nursing school care plans. And actually, I have some free care plans to give to you. So be sure to stick around until the end of the video and I will let you know where you can snag those. Hey, friend. I'm Christina Rafano from nursingschoolofsuccess.com and today we are talking about nursing school care plans. Yes, care plans. I know you're probably shaking in your boots right now, but trust me, they are so easy to do once you get them down. So I'm going to walk you through four easy steps to set you up for success to ace them. So before we dive into these steps, we need to first understand exactly what a nursing care plan is. So a nursing care plan is basically the process that a patient will go through to get better. It's their plan of care and their care plan. And to create these care plans, you as the nursing student need to first assess your patient. You need to understand their needs and their goals, and you need to create a plan of action to help them get there. So that's exactly what we're doing with these care plans. Now, care plans follow the nursing process. And if you need a refresher on the nursing process, be sure to check out the video that we have on that. I'll put a link in the description below. So definitely check that out if you need it. So care plans follow the nursing process, which is assessment, diagnosis, planning, implementation and evaluation. So the care plan goes like this. You need to assess your patient to find out what their needs are. You come up with an appropriate nursing diagnosis for them for where they're at currently. You need to set goals for where they want to be, do the interventions necessary to help them get there, and then finally, you will need to evaluate that whole process and their progress. So that is the overall concept of care plans. Now let's walk through, step by step, exactly how to make this happen. So the first step is to plan out exactly what you need to do before you go to clinical. You have to note what information you need on your patient before you go to clinical. That way you don't forget anything. So don't forget to ask them any questions or to assess anything. So you have a plan. You need to know exactly what your professor is expecting from you and your care plan. So you definitely want to go through all of that and know what you need to do before you go into clinical. So make a list of all the information that you need to get things like their patient history, how they ended up at the facility, what's been stressing them out lately, what support system they have, what their normal day looks like, things like that, anything like that. Your clinical instructor will lay out requirements for you. So make sure that you know exactly what those are so you don't forget any of them. That would be bad. Step two is to actually gather all of that information. You'll do your full head to toe assessment or maybe a focused assessment on your patient. You'll ask all of your questions and you'll write it all down. Now this is super important. You must write down all the information as you get it. Because let's be honest, your brain right now is overflowing with nursing school information, right? So if you don't write these things down, you will forget it. So make sure that you write everything as you are doing your nursing assessment. So now, if it's your first time doing an assessment, I really, really recommend that you actually take full, like full pieces of paper and write down as much as you can, word for word. Now, if you have a little more experience with assessments and you're a little more comfortable, and you're a little more comfortable talking with patients, you can really just use a brain sheet or maybe just a half piece of paper. If you're not familiar with what a brain sheet is, it's a handy dandy tool that nurses use to keep track of everything that they do during the shift. It's just a sheet of paper with boxes to fill in and organized places for you to take notes on. So you can use a brain sheet if you're comfortable with it, or you can just use a half sheet of paper. Now step number three is to find a quiet corner after your assessment to brain dump. Yes, you need to take a few minutes, step back, and literally write everything down that you can remember about that assessment. Maybe you didn't get to write those things down. That's your time. Now, this always happens. You go to write your care plan and you realize that you forgot something about your patient or you're missing a key piece of information that you needed. So really save yourself the stress later and just take a few minutes after your assessment to write everything down that you didn't get to write in the room. This really shouldn't take more than five minutes and you will definitely think yourself later. Now step four is to actually do it, actually write your care plan. So sit down at home, home or at the library or somewhere else. Quiet. Look through your notes and write your care plan. So look through the requirements again and use your amazing notes that you took at clinical to actually write down your patient profile and to write your care plan. And I actually have three bonus tips to help you do just that. So bonus tip number one, choose the most appropriate nursing diagnosis for your specific patient. This is what your instructor is looking for, my friend. They need to know that you actually know what you're doing and to prove that it starts with choosing the best nursing diagnosis for your specific patient. So if you choose a nursing diagnosis that doesn't apply to your patient, well, that's just telling your nursing instructor that you don't know what you're doing. And friend, I know it feels that way sometimes, but you actually do know what you're doing. You know more than you think you do. Trust me. So use all the of that amazing knowledge that you have and choose an appropriate nursing diagnosis for that specific patient. Now, if you need help with choosing a nursing diagnosis for your patient, be sure to check out the video that we have all about that and how to choose a great nursing diagnosis for your patient. I will put a link to that video below in the description. So that will definitely help you out. Now, bonus tip number two is make patient goals specific for your patient. Don't write a patient goal that they no interest in actually doing. This one is a big one. Sometimes we forget that patient goals are not about us, they are actually about the patient. So make sure that your patient goals are something that they're actually interested in working toward. So for example, if your patient smokes but they have no intention of quitting, maybe a patient goal of the patient will quit smoking by the time they discharge is not so good. That's not patient centric and it's not realistic for them. So make sure that you're actually writing patient goals that are specific for your patient. And bonus tip number three, the nursing interventions that you do are all about you. This is something I often see nursing students get hung up on. Nursing interventions are written as what the nurse or the nursing student will do and that's you. So your nursing interventions should be written as the nurse will so the nurse will educate the patient on healthy food choices to lower blood sugar, or the nurse will assess the patient's lung sounds every four hours. Things like that that are specific to your patient. So nursing interventions are written as what the nurse or the nursing student will do. Now be sure to check out the other care plan videos that we have for more tutorials on how to write great nursing school care plans. I will put a link to all of those below in the description. And just like I promised, I've got some free care plans for you, so I'll put a link to that below in the description as well so you can snag those right away. Did you like this video? Let me know. Please write the word awesome in the comments below and let me know that you liked it. And don't forget to click, subscribe and hit that bell so you never miss a video. Thank you so much for watching, friend. And now go become the nurse that God created only you to be. And I will see you right back here next time on the Nursing School School Show.